After Years of Trying, Virginia Finally Will Expand Medicaid

WASHINGTON — Virginia’s Republican-controlled Senate voted Wednesday to open Medicaid to an additional 400,000 low-income adults next year, making it all but certain that the state will join 32 others that have already expanded the public health insurance program under the Affordable Care Act.

Republican lawmakers in the state had blocked Medicaid expansion for four straight years, but a number of them dropped their opposition after their party almost lost the House of Delegates in elections last fall and voters named health care as a top issue.

The vote, on a budget bill that included the Medicaid expansion, came almost three months after the House approved a similar plan. Gov. Ralph Northam, a Democrat also elected last fall, has been a vocal proponent of the expansion and can now claim a victory that his predecessor, Terry McAuliffe, desperately wanted but never got.

The House was expected to pass the Senate bill quickly — possibly by the end of Wednesday — and send it to Northam’s desk. The measure includes a requirement that many adult recipients who don’t have a disability either work or volunteer as a condition of receiving Medicaid — a provision that was crucial to getting enough Republicans on board.

The Affordable Care Act gave states the option to expand Medicaid starting in 2014, and required the federal government to pay no less than 90 percent of the cost. Opponents said that even 10 percent was unaffordable for most states, and that the federal government might renege on paying its share, especially if the health law were repealed.

On a day when Virginia neared becoming one of the biggest states, by population, to expand the program to date — an important step forward for the Affordable Care Act — President Donald Trump boasted inaccurately at a bill signing that “for the most part we will have gotten rid of a majority of Obamacare.”

Efforts to expand the program are actually gaining steam in some other Republican states. With midterm elections approaching, advocates in Idaho and Nebraska are trying to get Medicaid expansion initiatives on their ballots. Their state legislatures have repeatedly refused to expand the program. Utah’s measure officially qualified for the ballot on Tuesday, and officials in Idaho are determining whether supporters have gathered enough signatures for their question to qualify.

Maine voters were the first in the nation to approve Medicaid expansion through a referendum last fall. But Gov. Paul LePage, a Republican, has blocked it from moving forward, and the matter is now tied up in court.

The federal government shares the overall cost of Medicaid with the states; the program covers about 75 million Americans, or 1 in 5. About 11 million of them were able to enroll as a result of states’ decisions to expand the program under the Affordable Care Act. Republican attempts to repeal the health law last year would have largely undone the Medicaid expansion and caused most of the new recipients to lose their coverage. Virginia’s House of Delegates voted to approve Medicaid expansion during the regular 60-day legislative session that ended in March. But the Senate, whose members were not up for re-election last fall, remained opposed. Lawmakers failed to pass a state budget then because of the issue.

“That is debt, and I have four kids who are going to be having to pay for that for the rest of their lives,” Sen. Amanda Chase, a Republican from Chesterfield, said of the federal funds spent on Medicaid expansion, explaining her vote against it on Wednesday. “It’s not just a fiscal burden, but it’s not the best solution for people who want real, quality health care.”

The turning point came in April when state Sen. Frank Wagner, a Republican from Virginia Beach, said he had changed his position and would support Medicaid expansion, joining one other Republican, Sen. Emmett W. Hanger Jr. of Augusta, and all 19 Senate Democrats. Wagner changed his mind after a work requirement was added to the plan.

State Sen. Ben Chafin, another Republican, also voted for Medicaid expansion on Wednesday.

“I came to the conclusion, for me and my district, that no just wasn’t the answer any longer,” Chafin, who represents an economically struggling district in southwestern Virginia, said on the Senate floor. “Doing nothing about the medical conditions, the state of health care in my district, just wasn’t the answer any longer.”

The approval did not come without last-minute drama: Thomas Norment, the Senate majority leader and steadfast opponent of Medicaid expansion, tried unsuccessfully to block it in the Senate Finance Committee on Tuesday, and again on the Senate floor on Wednesday, when he pushed to pass a version of the budget that did not include it. Instead, a substitute budget including amendments that allowed for Medicaid expansion, offered by Hanger, was approved.

Virginia’s plan would tax hospitals to generate revenue for the state’s 10 percent share of the roughly $2 billion annual cost.

The state currently has one of the most restrictive Medicaid programs in the country, covering mostly children and disabled adults. Childless adults are not eligible, and working parents cannot earn more than 30 percent of the federal poverty level, or $5,727 a year.

The Affordable Care Act allows states to expand Medicaid to adults earning up to 138 percent of the poverty level, which comes out to $16,643 for an individual.

Most of the remaining states that haven’t expanded Medicaid are in the South and Midwest, and are led by Republicans. Along with 32 states, the District of Columbia has expanded the program already.

This year, Republican governors and state lawmakers, encouraged by the Trump administration, have focused on adding new requirements for Medicaid eligibility, such as requiring adults without disabilities to work or volunteer, and many beneficiaries to pay premiums. Virginia would first expand Medicaid, then ask the federal government for permission to add a work requirement, under the plan the Senate approved Wednesday.